I was introduced to the concept of the learning health system or learning health care system last year, but when the topic came up again at a recent lecture, I felt compelled to know more. My basic search across Medline (PubMed), CINAHL, Embase, and Engineering Village yielded over 10,000 results [before deduplication], including both conceptual and research articles from various clinical specialties and informatics. However, a quick scan of the titles and abstracts uncovered little to no mention of the role of the health sciences or (bio)medical library in the learning health system (LHS).

That got me thinking: what might that role be?

I don’t have all the answers, but given the major part the LHS occupies in the culture of today’s academic medical center, I’m hoping this post can spark a conversation among health sciences librarians about ways we can help our institutions achieve the goals of the LHS.

Generally speaking, the learning health system can be described as a fusion of clinical and basic sciences, informatics/data sciences, and workplace culture, with the goal of continually improving the quality, safety, efficiency, and effectiveness of health care. Or, as one colleague eloquently stated, “The learning health system helps us improve how we care for patients while we are taking care of them.”

It dawned on me that this could be a key step in the evolution of evidence-based medicine/evidence-­based practice.

In the LHS, we are not using the biomedical literature to change practice, but instead identifying real-time data signals (via pragmatic clinical trials) within the electronic medical record to generate new knowledge, change clinical practice, and refine institutional policies and procedures. The literature’s influence remains—as the basis for determining which research projects to pursue—but it becomes secondary to real-time data. Then, once the findings are in hand, the literature helps validate and supplement those findings prior to their dissemination and adoption.

Could this be the beginning of real-time evidence-based medicine or evidence-based practice? If so, then there is definitely a place for libraries, information scientists, and knowledge management practitioners in the learning health system.

Of course, libraries have their collections of knowledge-based information resources, literature searching (and filtering) services, and collaboration spaces to offer, but I’m thinking we can do more than that. By identifying the local LHS information architecture, i.e., the flow of information in the research, clinical, or educational context, we can discover potential roles for the library. Understanding the flow of information allows us to identify how it enters the system, interacts with users, and is packaged for adoption. That understanding can also help us—in conjunction with the published literature—pinpoint and address the information needs and gaps within the LHS. That, to me, is where the opportunities for libraries reside.

This novel use of the literature will require knowledge management and knowledge extraction practices such as filtering, summarizing, synthesizing, or curating information. These contributions go beyond the saved searches or static bibliographies libraries traditionally offer, but they fall well within the librarian skillset. While the next steps of translating and integrating the literature and newly generated data into the electronic medical record will likely fall outside the library’s purview, the overall potential for collaboration will ultimately depend upon the relationship between the library, LHS leadership, and the medical center’s informatics and/or clinical decision support unit(s).

Depending on the organization and skills of library staff, we can position ourselves as the central information hub, collaboration space, literature searchers, and, in some cases, consultants in text mining, data mining, data visualization, or data management. By partnering with our institutions to achieve the goals of the LHS, we can strengthen relationships with our constituents and help them educate current and future health care practitioners, generate new knowledge from research, and improve health delivery and outcomes.

Philip Walker, MLIS, MSHI, is the Director of Vanderbilt University’s Annette and Irwin Eskind Biomedical Library. He has been a librarian at Eskind since 2012 and served as Interim Director from 2017-2018. Walker previously worked at Tulane University’s Rudolph Matas Library of the Health Sciences, the Texas Medical Center Library, and the Meharry Medical College Library.

As information flows from the data collection pipeline to research, curation, and publication, hospital librarians, especially those who practice closely with health care providers, become the human face of information servers. And like those data processing units that serve numerous users, these librarians, many of whom work alone as solo librarians, must be prepared to fill requests from all quarters.

Consider, for example, the following vignettes:

The Chief Operating Officer is launching the next phase of a project to reduce perinatal mortality and preterm births. The librarian continually provides the physicians, nurses, and social workers on the project committee with research articles on emerging causes, new treatments, and community-health approaches to improving outcomes.

A pre-op nurse talks with a colleague about a practice difference they have in monitoring a patient. She wants to know what the evidence says.

A nurse educator asks for help proofreading an article about a successful quality improvement project and confirming the proper citation format for the references.

A physician teaching medical students in Mongolia about the latest updates in women’s health asks, “Can you gather research articles that would address their population on this list of topics?”

The marketing department is updating the hospital’s website. They want to know where they can find consumer-friendly health care definitions.

Sometimes, that can all happen in one day!

But answering questions is not all we do.

A 2016 survey of solo librarians garnered responses from 383 professionals who reported on job duties. Using a pick list, respondents identified an average of nine different job duties for which they were responsible, from a high of 17 to a low of five. (To the best of the authors’ knowledge, no data exists regarding the total number of solo librarians in health care, so the survey results are limited.)

Judging by their selections, a job description that fairly represents a solo librarian’s qualifications might include strong literature search skills across multiple databases, managing electronic resources, experience instructing clinicians, fluency with medical terminology, and advanced budget skills. Working with researchers and rounding with clinical staff may also be required, as might serving on hospital committees, including the Institutional Review Board. Strong outreach practices are encouraged.

Even with such a diverse skill set, many of these librarians lack job security. While many solos are regarded as valuable members of their health care teams, they also know their jobs may not survive the next hospital merger or budget crisis. In fact, listserv news of hospital library closures, anticipated or unexpected, can turn that fear into an ever-present companion.

Yet being resilient may be a solo librarian’s strongest quality. We always have an eye toward future trends, both in our hospitals and in the information arena. Listen to our conversations, and you will hear us talking about ways to use data to demonstrate to our administrators our daily contributions to patient safety, improved outcomes, case management, and the hospital’s overall return on investment.

And though we call ourselves “solo librarians”—and might be managing a hospital’s library services alone or with a skeleton staff of part-timers or volunteers—we know we do not work in isolation.

Our colleagues in academia and at the National Network of Libraries of Medicine nourish us with webinars about the basics of electronic medical record data, innovative instructional methods, consumer health resources, and best uses for a variety of NLM databases. Many of them are our professional best friends, supporting us when we need clarity on best practices in running our library or offering support with a perplexing situation.

We also rely upon the National Library of Medicine, both for its resources and its vision. We view NLM’s 10-Year Strategic Plan as a roadmap to where we are headed. Solo librarians are well-prepared to support Goals 2 and 3 (PDF) of the plan, whether with skills we already have or others we need to develop. Supporting biomedical and health information access and dissemination is already part of our lives; learning to identify and appreciate the capabilities of new digital products is on our must-do list. With training and guidance, we can be the link that facilitates data science proficiency within our institutions and healthy living within our communities.

But like information servers, solo librarians are most valuable when we are kept updated, valued, and used. For this, we count on those higher up the knowledge-creation ladder to share their wisdom with us, value our expertise in local health dynamics, and remind others to use us as resource partners.

Louise McLaughlin, MSLS, stepped into the role of Information Specialist at Woman’s Hospital in Baton Rouge, Louisiana, when her predecessor retired, and her job as assistant librarian was eliminated. She has reached out to friends in similar settings and established a monthly Solo Chat and worked as co-convener of the Medical Library Association’s Solo Special Interest Group. Louise has authored or co-authored several articles on solo librarianship for the Journal of Hospital Librarianship, the National Network, and other association publications.

Recently there have been a number of messages going out to medical library discussion lists announcing the unfortunate closing of yet another hospital library. It seems that, in this era of for-profit medicine, libraries are looked upon as luxuries. Yet those of us who work in them know our services are not only needed but valued by the physicians, nurses, and other health professionals who regularly call on us to answer their questions.

Anyone who doubts the need for information professionals in a hospital probably doesn’t understand what we do.

Many people think everything is on Google, and it might be, but it’s not easy to find. Medical literature is found in databases that often require time, patience, and skill to search, and a subscription to access.

Furthermore, someone has to assess the information needs of the hospital community, negotiate pricing for and purchase the resources that best fit those needs, work with vendors and the institution’s IT department to set up access to the resources, and then navigate the resources to retrieve what is in them.

Searching databases takes time, patience, and skill. While it is certainly possible for medical professionals to have the patience and skill, do they really have the time? How many nurses and physicians, in the course of a busy 12-hour shift, can find the time to search the medical literature?

A point-of-care tool can give a quick answer, but if something in-depth or out of the ordinary is required, those tools aren’t usually helpful. More specialized skills and knowledge of how information is organized are needed to answer complex clinical questions. Hospital librarians have not only the educational background, but also the experience to navigate databases and retrieve hard-to-find information.

Many people don’t seem to understand what a librarian does, why it’s different from a Google search, and that the “information bubble” is as real in medicine as it is in other disciplines. They may also be unaware that googling can lead to selective retrieval of information and confirmation of bias. The groundbreaking 1992 Rochester study (Marshall) and the 2013 follow up (Marshall) showed the vast majority of physicians changed the course of patient treatment based on library-provided information—80% in 1992, 75% in 2013. This telling statistic confirms that librarian-mediated searches and resources curated by hospital librarians do make a difference.

Every time a hospital library closes, we send out a call to arms and vow to stem the tide of attrition in our ranks. Yet the task of saving hospital libraries has become increasingly difficult. Once mandated by law, requirements for hospital libraries have been dropped by regulatory agencies—first by the Health Care Financing Administration in 1986, then The Joint Commission in 1993. In the climate of expense cuts, this shift has made hospital libraries an easy target. Point-of-care products, which synthesize current evidence in support of decision-making regarding tests, interventions, or diagnosis, have also made it more difficult to convince administrators that other information resources are still needed—and oftentimes more reliable. And with health systems increasingly consolidating, health system administrators—now removed from everyday hospital concerns—may see the library only as an expense and not as an asset their hospital staff value and rely upon.

Although hospital librarians have primarily concentrated on providing patient-care information, we also support a number of different important hospital functions and initiatives including research, information literacy training, graduate medical education, undergraduate and graduate nursing and allied health education, continuing education, Magnet preparation, evidence-based nursing practice, and hospital administrative and competitive intelligence research. Cuddy (2005) described a similar assessment of the breadth of library contributions in the Fuld Campus study.

The value of a hospital librarian has been proven. And with doctors and nurses asked to practice evidence-based medicine, is it really wise to close hospital libraries and dismiss the professionals best equipped to find that evidence?

What steps can we take to ensure the latest announcement of a hospital library closing is the last?